HomeMy WebLinkAboutSeptic Pumping Slip - 247 BRIDGES LANE 12/28/2015 Commonwealth of Massachusetts
CITYITown of North e Andover
Sys
t M pumping Recor d
Form 4
wy local Boards of Health. Other forms may be used, but the
DEP has provided this form for use by same as that provided here, Before using this form, check with your
information must be substantially the s se. The System pumping Record must b'e submitted Lo
local Board of Health to determine the form they u days from the pumping,date in
the local Board of Health or other approving authority within 14
accordance with 310 CM R 15-351.
A. Facility information
important When
filling out forms 1 System Location*
on the computer,
use only the tab 01886
key to move your Address Ma
cursor-do not North Andover State zip code
use the return -C-ity/Town
key.
2. System Owner�
N am e
Address(if different from location)
State Zip Code
Cityaovin
Telephone Number
B. pumping Record
11 kLq-- 2, Quantity Pumped: Gallons
1. Date of Pumping Date
3, Type of system: E] Cesspool(s) M/Septic Tank E] Tight Tank F-I Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No -if yes, was it clearied? ❑ Yes ❑ No
5. Condition of System:
6. System'Pumped By:
Vehicle License Number
ewart's septic Service
Company
7. Location where contents were disposed, a 0183 5 1
Stewaff Bradford,Pre-treatment Plant, 20 So. Mill -
Date
Signature of Hauler ,Signature of Receiving Facility Date,,,
System Pumping Record-Page
t5form4,doc-03/06
Commonwealth ®f Massachusetts,
---- xa City/Town of North Andover �
m -
System Pumping Record 0,A/N
Form 4 ,.. ., .
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health
of Health or other approving i gtauthority within 14 days from pntghe Record pumping dabs inubmitted to
the local Board
accordance with 310 CMR 15.351.
A. Facility information
Important:When
filling forms
the computer, � r
1. System Locatian-
use only the tab --- —
key to move your Address
cursor-do not North Andover Ma
--_________ Zip Code
use the return -----_----_-------------- State
City/Town
key.
2. System Owner: '
Name
m�vn
Address(if different from location)
------------
State Zip Code
__ ------------- ---———__
City/Town
Telephone umioer
B. Pumping cord
1. Date of Pumping ate --- - 2. Quantity Pumped: Gallons
� Grease Trap
3. Type of system: ❑ Cesspool(s) „( Septic Tank ❑ Tight Tank p
❑ Other (describe): --_-----------
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
YJ
6. System Pumped By:
------- --------- Vehicle License Number
Name
Stewart's Septic Service — _--
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
4Signat f H"�u er Date
of Receiving Facility Date
System Pumping Record•Page 1 of 1
t5form4.doc•03/06
Commonwealth of Massachusetts
City/Town of No.Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
x.NiMWoiArpuyx. (!wwfi4lnW!mw!!µvWeal'PNWMrc!iwa
A. Facility Information
Important:
When filling out 1. System L ation:
forms on the �)
computer, use �
only the tab key Address
to move your No.Andover Ma 018-116
cursor-do not Citylrown State Zip Code
use the return
key. 2. System Owner:
I LIE
Name
� Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2. Quantity
1. Date of Pumping Date y Pum p ed: Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): �\
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. S tem Pumped y:
Name
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 —
Signature of Hauler Da#e. 12-1 /
Signature of ReceiviAg Facility D
t5form4.doc•03/06 System Pumping Record.Page 1 of 1
II
i
Commonwealth of Massachusetts
RIF
w �E
City/[Town of
System Pumping Record EC 1 io
F®t'Pr1 4 TOWN OF NtTH NDC� P
DEP has provided this form for use by local Boards of Health. Other forms
information must be substantially the same as that provided here. Before using this form, check wi your
local Board of Health to determine the form they use, The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: 1. System L Lion:
When filling out
forms on the
computer,use
only the tab key Address 01866
to move your North Andover ma
cursor-do not State Zip Code
City/Town
use the return
key, 2, System Owner:
Name
�_"'� Address(lf different from location)
CitylTown
State Zip Code
Telephone Number
B. Pumping Record /n—c C
1. Date of Pumping Date Jfl . Quantity Pumped: Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. tem Pumpe �y:
Name Vehicle License Number
Stewart Septic Service
Company
7 L cation where contents were disposed:
to rks Pre tre went Plant 20 So, Mill St, Bradford Ma 01835
Signature of Ha ler Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 1
t5form4.doc^43106
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f l DER.has provided this form for use by local Boards of Health. he! y t, m,'P.iu' p ti i
tr s �w, , , •.. ar � � "'� o�rd must
be submitted to the.local'Board of Health or other approving authority,
X Facility,information
' r. •
a,,,yVhen Nang out 1: System Looatiom
fams'coenputar�user :' , ' C�.. ....
only the tab key Addr®s
Y our ,
to move '
cur -do notCI /Town Ste Zip Code
uss the itum �' '
2 y
8 0',-System t m w
ner, fl .•
moll
��� 4 •t ' rfo""a� &^' "
N 7,
"'� i' Addroaa(If different from location) ;
City/Town State .t Z!p Code
Telephone Number
PumP14 ReoOr'd
rr Y, tirtti,ty�r, rr1t ,�.tW /lV�'�rit �1�, f
, tl Pumped:
1,: Dafe`of Pumping Dale 2 QuantY Pum p Gallons
Typo of system ❑ Cesspool(s) ptic Tank ❑ Tight Tank
®' Other(describe),
4 Effluent Tee Filter prosent? ❑ Yes 0 If yes, was It cleaned? El Yes ❑ No
'{ 6` Condition of Systm:'
.. lrt. `,.ti ° �Y'.trr 'ri '�t�,�� i;f. lit `Y,�'i�, : � rl���t tlh,,,� � �-"�l��.d✓" ."'7
r
y t
Sy Pumped
I.dame r,l n, a, „r��; ', (� //J�jVehicle Ucen$e Number
Conip t�Yl ly ftrf ''�Y(S y�-Ir 11,1 pfl,
� > !�. ' •rj.���Jhyr„�h�' 11i�'yW°-LK'r t�l i�SY.'.!r,4rW •M;��
LocaUi h4here Contents Were Oposed:
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> Stanatwe of Haul®r,,lr;;:,< < ' ,,.-,' .. . Date
http;//www.mas'sr gov/dep/water/approvals/Wforms,htm#Inspect
t5fomti4,doc•06/03 System Pumping Record Page t of t
-- --_ ......--
j
t
TOWN QF`NO$,.TH ANDOVER ."
SYSTEM PUMPING RECORD
DATE
SYSTEM OWNER&ADDRESS SYSTEM LOCATI�7 �
DATE OF PUMPING
QUANTITY'PtZMPED
CESSPOOL NO SEPTIC TANK NO YES ,
NATURE OF SERVICE;;,RQT), TINE EMERGENCY
OBSERVATIONS;
GOOD CONDITION a FULL TO COVER
MAW GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS--FLOODED
SOLID CARRYOVERS OTHER EXPLAIN
SYSTEM PUMPED BY / l
=' A//� , _
COMMENTS;
CONTENTS TRANSFERRED TO i ,Y, J ,/Al/o,�
i
I
J
1
TOWN OF NORTH R
SYSTEM PUMPING RECORD
DATE: / � G
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
I`
DATE OF PUMPING: "1 "� QUANTITY PUMPED _GALLONS l
CESSPOOL: NO YES SEPTIC TANK: NO YES D�
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: